A 35-year-old yoga instructor presents to the General Practitioner (GP) with complaints of feeling constantly fatigued. During the consultation, she also mentions experiencing widespread, non-specific itching.
Upon examination, the GP observes generalised excoriation, but no other significant findings. Blood tests reveal an elevated alkaline phosphatase level, leading to a suspicion of primary biliary cholangitis.
What is the most specific symptom of primary biliary cholangitis?
A 44-year-old man with diagnosed primary sclerosing cholangitis (PSC) had been taking cholestyramine and vitamin supplementation for the last 3 years. He had ulcerative colitis which was in remission, and colonoscopic surveillance had not shown any dysplastic changes. His only significant history was two episodes of cholangitis for which he had to be hospitalised in the past year. On examination, he was mildly icteric with a body weight of 52 kg. At present, he had no complaints, except fatigue.
What is the next best treatment option?
A 23-year-old woman developed sudden-onset, severe epigastric pain 12 hours ago. She subsequently began having episodes of nausea and vomiting, especially after trying to eat or drink. The pain now feels more generalised, and even slight movement makes it worse. She has diminished bowel sounds and exquisite tenderness in the mid-epigastrium with rebound tenderness and board-like rigidity. Her pulse is 110 bpm and blood pressure 130/75. She reports taking ibuprofen for dysmenorrhoea. She had last taken ibuprofen the day before the pain began.
What is the most likely diagnosis?
A 38-year-old woman presents to the Emergency Department (ED) with chest and abdominal pain, following three days of severe vomiting secondary to gastroenteritis. She reports pain being worse on swallowing and feels short of breath. On examination, she looks unwell and has a heart rate of 105 bpm, a blood pressure of 110/90 mmHg, a respiratory rate of 22 breaths/minute and a temperature of 38 °C. Boerhaave syndrome is suspected.
What is the most appropriate initial investigation, given the suspected diagnosis?
A 67-year-old woman complains of epigastric pain, vomiting and weight loss. The surgeon suspects gastric cancer and sends her for endoscopy. Where is the cancer likely to be located?
A 50-year-old man presents to the Emergency Department with excruciating chest pain. He has had severe vomiting and retching over the last 24 hours after he ate some off-food at a restaurant. The last four episodes of vomiting have been bloody and he states that he has vomited too many times to count. The patient has a past medical history of type 2 diabetes mellitus and hypertension.
His observations are shown below:
Temperature 38.9 °C
Blood pressure 95/59 mmHg
Heart rate 115 beats per minute
Respiratory rate 24 breaths per minute
Sp(O2) 95% (room air)
Physical examination of the chest reveals subcutaneous emphysema over the chest wall. His electrocardiogram (ECG) is significant for sinus tachycardia without ischaemic changes and his blood tests results are shown below:
Investigation Result Normal value
White cell count 21.5 × 109/l 4–11 × 109/l
C-reactive protein 105.5 mgl 0–10 mg/l
Haemoglobin 103 g/l 135–175 g/l
Which of the following is the most likely diagnosis?
A 50-year-old woman with a history of multiple gallstones is presenting with jaundice due to a common bile duct obstruction caused by a large stone. What biochemical abnormalities are expected to be observed in this patient?
A patient in their mid-40s is transferred from a District General Hospital to the Burns and Trauma Centre. They arrive intubated. The history is that they were on some scaffolding holding a pole, which they touched onto an overhead powerline, causing electrocution. They fell backwards and were found to be in ventricular fibrillation (VF) arrest by paramedics, who resuscitated them with defibrillation. They have small burns on their hands and also their left foot. On arrival at the Trauma Centre, they have a full CT traumagram which showed no other injuries. Their C-spine has been radiologically cleared. You are examining them, and you notice they have a swollen, tight left leg. The nurse brings you their blood gas, and you see they have a potassium level of 6.3 and they have mild metabolic acidaemia, with a pH of 7.21. Their urine is tea-coloured (catheter in situ), with a creatine kinase (CK) level of 1232.
What is the best course of action?
A 50-year-old man visits his primary care physician complaining of pain in the back of his ankle and difficulty walking. He reports hearing a loud snap while participating in a 5-km obstacle course. Upon examination, the physician observes swelling at the back of the ankle and a positive Simmonds test. The patient is diagnosed with a ruptured Achilles tendon. What is the best course of action to promote healing of the damaged tendon?
A 48-year-old woman is brought to the Emergency Department following a motor vehicle accident. The patient’s car was parked in the street when a small car hit her vehicle from behind. She was seated and restrained in the driver’s seat and was not ejected from the vehicle. The airbags did not deploy. The ambulance staff reported that the patient did lose consciousness at the scene but now is alert and orientated.
Her primary and secondary surveys are normal. Her neurological examination is also normal and she has full cervical spine range of motion. The patient has a Glasgow Coma Scale of 15/15.
Her observations and blood tests results are shown below.
Temperature 36.9 °C
Blood pressure 121/59 mmHg
Heart rate 67 beats per minute
Respiratory rate 18 breaths per minute
Sp(O2) 98% (room air)
Her computed tomography (CT) scan of the head, cervical spine, chest, abdomen and pelvis is normal. She is still complaining of diffuse, muscular pain throughout her body which was not present before the accident. She is able to mobilise slowly around the ward. She states that prior to the accident she was able to mobilise independently without difficulty and without pain.
Which of the following is the most likely diagnosis?